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The Measles Outbreak

and the Role of Vaccine


Hesitancy
Daniel Salmon, PhD, MPH
Associate Professor
Departments of International Health &
Health, Behavior and Society
Deputy Director, Institute for Vaccine
Safety

Vaccine Hesitancy
Persons or families who:
Refuse all or some vaccines
Delay some vaccines, but accept others
Accept all vaccines, but remain concerned

http://www.who.int/immunization/sage/meetings/2013/april/1_
Model_analyze_driversofvaccineConfidence_22_March.pdf

http://www.cdc.gov/vaccines/imz-managers/coverage/nis/child/figures/2013-map.html
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Parental Practices
83% vaccinated with recommended
schedule
11% planned to vaccinate with
recommended schedule
5% vaccinated with some but not all
vaccines
2% intended to not vaccinate at all
376 parents of children 1-6 years from 2010
HealthStyles Panel Survey
Kennedy, Health Affairs, 2011

77% of Parents Reported Vaccine Concerns

Painful to receive so many shots (38%)


Too many vaccines at one doctors visit (36%)
Too many vaccines if first two years of life (34%)
May cause fevers (32%)
May cause learning disabilities, such as
autism (30%)
Ingredients unsafe (26%)
Not tested enough for safety (17%)
May cause chronic disease (16%)
Unlikely to get diseases (11%)
Kennedy, Health Affairs, 2011

Characteristics of Unvaccinated (Zero


Dose) vs. Under-vaccinated Children
Unvaccinated children more likely to be:
White
Belong to households with higher
income
Married mother with a college education
Live with 4 children

Smith, Pediatrics, 2004

Northern California Kaiser


Preschool Children Vaccination by
Time Period

UnderImmunized

20022005
8.1%

20062009
9.2%

20112012
12.4%

0.7%

1.0%

2.3%

NA

NA

3.5%

4:3:1:2:3:1:4 series
by 24 months

Shot-limiters
Fully Immunized at
36 months but never
>2 injections on a
day

> 1 Vaccine
Refusal
Diagnosis

Lieu, Pediatrics, 2015

Types of Exemptions to School


Immunization Requirements, 2015

http://www.ncsl.org/research/health/school-immunizationexemption-state-laws.aspx

Associations between State Exemption Policies


and Pertussis Incidence, 1986-2004
Adjusted IRR
(95% CI)

Type of Exemption
Only Religious Exemption

Reference

Personal Belief Exemption

1.48 (1.03-2.13)

Exemption Ease
Difficult

Reference

Medium

1.35 (0.96-1.91)

Easy

1.53 (1.10-2.14)
Adjusting for allowing parental signature for school immunization forms, proportion inside urbanized area,
income (11 categories), and education (7 categories)

Omer, JAMA, 2006

Mean (95% CI) Rates of Nonmedical Exemptions


by Type & Ease of Exemption, 20062011, US

Omer et al., NEJM, 2012

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Increased Risk of Disease


for Children with
Exemptions

Measles
Pertussis
Haemophilus influenzae type b
Varicella
Pneumococcal
CDC, MMWR, 2008; Glanz, Arch Pediatr Adolesc Med,
2010; Glanz, Vaccine, 2011; Parker, JID, 2010; Salmon,
JAMA, 1999; Glanz Pediatrics, 2009; Omer, AJE, 2008;
Omer, JAMA, 2006, Atwell, Pediatrics, 2013.

Pertussis Space-time Clusters &


Exemptions Clusters

Overlap of
Exemptions
Clusters with
Pertussis Clusters
Adjusted1 OR
3.4 (2.8 4.1)

Omer, AJE, 2008

Pertussis Space-time Clusters and


Exemption Clusters,
20052006 to 20092010

Atwell, Pediatrics, 201314

Why Are Some Parents


Vaccine Hesitant?

15

Post hoc ergo propter


hoc
"after this, therefore because of
this", is a logical fallacy since that
event followed this one, that event
must have been caused by this one.

http://dictionary.sensagent.com/post+hoc+ergo+propter+hoc/en-en/

Risks Perceived to be
Greater
Less Risk

More Risk

Voluntary

vs Involuntary
.

Individual Control

vs System Control
.

Omission

vs Commission
.

Natural

vs Manmade
.

Predictable

vs Unpredictable
.

Not Dreaded

vs Dreaded
.

Familiar

vs Exotic
Adapated Chen, Pediatr Ann, 1998
.
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Chen, Pediatr Ann, 1998

Comparison of 20th Century Annual and Current


Reported Morbidity, Selected VaccinePreventable Diseases & Vaccine Adverse Events,
United States, 2014
Disease

20th Century Annual Morbidity

Smallpox
Diphtheria
Measles
Mumps
Pertussis
Polio (paralytic)
Rubella
Cong. Rubella Synd.
Tetanus
H.Influenzae type b and
unknown ( < 5 yrs)
Total

29,005
21,053
530,217
162,344
200,752
16,316
47,745
152
580
20,000
1,064,854

2014

% change

0
1
628
1,151
28,660
0

100%
>99%
>99%
99%
86%
100%

8
0
21
27

>99%
100%
96%
>99%

30,496

97%

Comparison of 20th Century Annual and Current


Reported Morbidity, Selected VaccinePreventable Diseases & Vaccine Adverse Events,
United States, 2014
Disease

20th Century Annual Morbidity

Smallpox
Diphtheria
Measles
Mumps
Pertussis
Polio (paralytic)
Rubella
Cong. Rubella Synd.
Tetanus
H.Influenzae type b and
unknown ( < 5 yrs)
Total
Reported Vaccine
Adverse Events*

29,005
21,053
530,217
162,344
200,752
16,316
47,745
152
580
20,000
1,064,854
0

2014

% change

0
1
628
1,151
28,660
0

100%
>99%
>99%
99%
86%
100%

8
0
21
27

>99%
100%
96%
>99%

30,496

97%

10,824

100%

* Reported to VAERS may or may not be due to vaccination

Parents Perceptions by
Child's Vaccination Status

p<0.01

p<0.01

p<0.01

p<0.01

p<0.01

p<0.01

Salmon, AJPH, 2005

Other Contemporary Issues


Trust in corporations and govt low
Fear of pharmaceutical industrial complex
Growing interest in natural products - green our
vaccines
Changing medical model
Shared decision making > paternalism
More patients in less time
Internet
The role of the media

Media vs. Science Talking about


Vaccines
Media
Focus on the anecdote
False Balance
Sensationalism

Science
Dismisses anecdote for data
Considers and discusses limitations of
study
Interprets with caution
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Falsehood flies, and the truth


comes limping after. Jonathan Swift,The
Examiner, Nov. 9, 1710

33% of
Americans

Reject the idea of


Evolution

39% of
Americans

No Solid Evidence
the Earth has
been Warming

(Pew, 2013)

(Pew, 2014)

33% of
American

Believe
Vaccination Can
Cause Autism

What To Do About Vaccine


Hesitancy
Change how the media reports on vaccines

Changes to State Exemption Laws


Restrict versus eliminate non-medical exemptions
Continue to enhance safety science
Scientific opportunities
Parental concerns
Rapid independent review of issues
Empower providers with tools, strategies, and
improved compensation for risk communication
Individual level interventions that are effective

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